Glycated hemoglobin vs fasting plasma glucose as a predictor of left ventricular dysfunction after st-elevation myocardial infarction

The World Health Organization and the American Diabetes Association recommend a level of glycated hemoglobin (HbA1c) ≥ 6.5% as diagnostic for diabetes. However, concordance between fasting plasma glucose (FPG) and HbA1c levels in acutely unwell patients is unknown. Furthermore, the prognostic value of HbA1c for left ventricular (LV) dysfunction is unclear. This study aimed to evaluate the concordance between HbA1c levels and FPG in consecutive patients with acute ST-elevation MI (STEMI) and compare their prognostic value in predicting LV dysfunction and elevated filling pressures on echocardiography.A total of 142 patients with a first incidence of STEMI were prospectively recruited. LV diastolic function was defined as mean septal and lateral early diastolic velocities (average e'); filling pressure was the ratio of transmitral E velocity to average e' (average E/e').Mean FPG and HbA1c levels were 7.7 ± 2.8 mmol/L and 6.5% ± 1.6%, respectively. Of 109 patients without previous diabetes, HbA1c levels identified an additional 18 patients (16.5%) as having diabetes, and the concordance with FPG was poor. Between diabetic and nondiabetic patients, there were no differences in LV end-diastolic volume (116 ± 37 vs 118 ± 43 mL; P = 0.78), end-systolic volume (69 ± 33 vs 68 ± 35 mL; P = 0.93), and ejection fraction (42 ± 12 vs 44 ± 11%; P = 0.49). On multivariable analyses, average e' was independently associated with HbA1c (β = -0.161; P = 0.045) but not FPG (P = 0.82). Similarly, average E/e' was independently associated with HbA1c (β = 0.168; P = 0.04) but not FPG (P = 0.32). Receiver operating characteristic curve analysis showed that an HbA1c cutoff of 6.4% (area under the curve, 0.68; P = 0.002) was associated with an elevated LV filling pressure.Only HbA1c was independently associated with impaired LV diastolic function and increased filling pressures after STEMI

One Loop Renormalization of the Littlest Higgs Model

In Little Higgs models a collective symmetry prevents the Higgs from acquiring a quadratically divergent mass at one loop. This collective symmetry is broken by weakly gauged interactions. Terms, like Yukawa couplings, that display collective symmetry in the bare Lagrangian are generically renormalized into a sum of terms that do not respect the collective symmetry except possibly at one renormalization point where the couplings are related so that the symmetry is restored. We study here the one loop renormalization of a prototypical example, the Littlest Higgs Model. Some features of the renormalization of this model are novel, unfamiliar form similar chiral Lagrangian studies.Comment: 23 pages, 17 eps figure

Bayesian estimation of incomplete data using conditionally specified priors

In this paper, a class of conjugate prior for estimating incomplete count data based on a broad class of conjugate prior distributions is presented. The new class of prior distributions arises from a conditional perspective, making use of the conditional specification methodology and can be considered as the generalisation of the form of prior distributions that have been used previously in the estimation of in- complete count data well. Finally, some examples of simulated and real data are given

Temporal trends and lesion sets for persistent atrial fibrillation ablation: a meta-analysis with trial sequential analysis and meta-regression

BACKGROUND: Ablation for persistent atrial fibrillation (PsAF) has been performed for over 20 years, although success rates have remained modest. Several adjunctive lesion sets have been studied but none have become standard of practice. We sought to describe how the efficacy of ablation for PsAF has evolved in this time period with a focus on the effect of adjunctive ablation strategies. METHODS: Databases were searched for prospective studies of PsAF ablation. We performed meta-regression and trial sequential analysis. RESULTS: A total of 99 studies (15 424 patients) were included. Ablation for PsAF achieved the primary outcome (freedom of atrial fibrillation/atrial tachycardia rate at 12 months follow-up) in 48.2% (5% CI, 44.0-52.3). Meta-regression showed freedom from atrial arrhythmia at 12 months has improved over time, while procedure time and fluoroscopy time have significantly reduced. Through the use of cumulative meta-analyses and trial sequential analysis, we show that some ablation strategies may initially seem promising, but after several randomized controlled trials may be found to be ineffective. Trial sequential analysis showed that complex fractionated atrial electrogram ablation is ineffective and further study of this treatment would be futile, while posterior wall isolation currently does not have sufficient evidence for routine use in PsAF ablation. CONCLUSIONS: Overall success rates from PsAF ablation and procedure/fluoroscopy times have improved over time. However, no adjunctive lesion set, in addition to pulmonary vein isolation, has been conclusively demonstrated to be beneficial. Through the use of trial sequential analysis, we highlight the importance of adequately powered randomized controlled trials, to avoid reaching premature conclusions, before widespread adoption of novel therapies

Artificial Intelligence Algorithms to Diagnose Glaucoma and Detect Glaucoma Progression: Translation to Clinical Practice

Purpose: This concise review aims to explore the potential for the clinical implementation of artificial intelligence (AI) strategies for detecting glaucoma and monitoring glaucoma progression. / Methods: Nonsystematic literature review using the search combinations "Artificial Intelligence," "Deep Learning," "Machine Learning," "Neural Networks," "Bayesian Networks," "Glaucoma Diagnosis," and "Glaucoma Progression." Information on sensitivity and specificity regarding glaucoma diagnosis and progression analysis as well as methodological details were extracted. / Results: Numerous AI strategies provide promising levels of specificity and sensitivity for structural (e.g. optical coherence tomography [OCT] imaging, fundus photography) and functional (visual field [VF] testing) test modalities used for the detection of glaucoma. Area under receiver operating curve (AROC) values of > 0.90 were achieved with every modality. Combining structural and functional inputs has been shown to even more improve the diagnostic ability. Regarding glaucoma progression, AI strategies can detect progression earlier than conventional methods or potentially from one single VF test. / Conclusions: AI algorithms applied to fundus photographs for screening purposes may provide good results using a simple and widely accessible test. However, for patients who are likely to have glaucoma more sophisticated methods should be used including data from OCT and perimetry. Outputs may serve as an adjunct to assist clinical decision making, whereas also enhancing the efficiency, productivity, and quality of the delivery of glaucoma care. Patients with diagnosed glaucoma may benefit from future algorithms to evaluate their risk of progression. Challenges are yet to be overcome, including the external validity of AI strategies, a move from a "black box" toward "explainable AI," and likely regulatory hurdles. However, it is clear that AI can enhance the role of specialist clinicians and will inevitably shape the future of the delivery of glaucoma care to the next generation. / Translational Relevance: The promising levels of diagnostic accuracy reported by AI strategies across the modalities used in clinical practice for glaucoma detection can pave the way for the development of reliable models appropriate for their translation into clinical practice. Future incorporation of AI into healthcare models may help address the current limitations of access and timely management of patients with glaucoma across the world

Effects of intrauterine exposure to synthetic glucocorticoids on fetal, newborn, and infant hypothalamic-pituitary-adrenal axis function in humans : a systematic review

BACKGROUND: Synthetic glucocorticoids are commonly used in reproductive medicine. Fetal organ systems are highly sensitive to changes in the intrauterine environment, including overexposure to glucocorticoids. Structural and functional alterations resulting from such changes may persist throughout life and have been associated with diverse diseases. One system that could be particularly sensitive to fetal glucocorticoid overexposure is the hypothalamic-pituitary-adrenal (hpa) axis. Many human studies have investigated this possibility, but a systematic review to identify consistent, emergent findings is lacking. METHODS: We systematically review 49 human studies, assessing the effects of intrauterine exposure to synthetic glucocorticoids on fetal, neonate, and infant hpa function. RESULTS: Study quality varied considerably, but the main findings held true after restricting the analyses to higher-quality studies: intrauterine exposure to synthetic glucocorticoids reduces offspring hpa activity under unstimulated conditions after pain but not pharmacological challenge. Although reduced unstimulated hpa function appears to recover within the first 2 wk postpartum, blunted hpa reactivity to pain is likely to persist throughout the first 4 months of life. There is some evidence that the magnitude of the effects is correlated with the total amount of glucocorticoids administered and varies with the time interval between glucocorticoid exposure and hpa assessment. CONCLUSIONS: This systematic review has allowed the demonstration of the way in which intrauterine exposure to various regimens of synthetic glucocorticoids affects various forms of hpa function. As such, it guides future studies in terms of which variables need to be focused on in order to further strengthen the understanding of such therapy, whilst continuing to profit from its clinical benefits

Web-based patient-reported outcome measures for personalized treatment and care (PROMPT-Care) : multicenter pragmatic nonrandomized trial

Background: Despite the acceptability and efficacy of e–patient-reported outcome (ePRO) systems, implementation in routine clinical care remains challenging. Objective: This pragmatic trial implemented the PROMPT-Care (Patient Reported Outcome Measures for Personalized Treatment and Care) web-based system into existing clinical workflows and evaluated its effectiveness among a diverse population of patients with cancer. Methods: Adult patients with solid tumors receiving active treatment or follow-up care in four cancer centers were enrolled. The PROMPT-Care intervention supported patient management through (1) monthly off-site electronic PRO physical symptom and psychosocial well-being assessments, (2) automated electronic clinical alerts notifying the care team of unresolved clinical issues following two consecutive assessments, and (3) tailored online patient self-management resources. Propensity score matching was used to match controls with intervention patients in a 4:1 ratio for patient age, sex, and treatment status. The primary outcome was a reduction in emergency department presentations. Secondary outcomes were time spent on chemotherapy and the number of allied health service referrals. Results: From April 2016 to October 2018, 328 patients from four public hospitals received the intervention. Matched controls (n=1312) comprised the general population of patients with cancer, seen at the participating hospitals during the study period. Emergency department visits were significantly reduced by 33% (P=.02) among patients receiving the intervention compared with patients in the matched controls. No significant associations were found in allied health referrals or time to end of chemotherapy. At baseline, the most common patient reported outcomes (above-threshold) were fatigue (39%), tiredness (38.4%), worry (32.9%), general wellbeing (32.9%), and sleep (24.1%), aligning with the most frequently accessed self-management domain pages of physical well-being (36%) and emotional well-being (23%). The majority of clinical feedback reports were reviewed by nursing staff (729/893, 82%), largely in response to the automated clinical alerts (n=877). Conclusions: Algorithm-supported web-based systems utilizing patient reported outcomes in clinical practice reduced emergency department presentations among a diverse population of patients with cancer. This study also highlighted the importance of (1) automated triggers for reviewing above-threshold results in patient reports, rather than passive manual review of patient records; (2) the instrumental role nurses play in managing alerts; and (3) providing patients with resources to support guided self-management, where appropriate. Together, these factors will inform the integration of web-based PRO systems into future models of routine cancer care